Third, Fourth, and Sixth Cranial Nerve Palsies in Pituitary Apoplexy

• Authors: Rabih Hage, Emory University; Sheila R. Eshraghi, Emory University; Nelson Oyesiku, Emory University; Adriana Ioachimescu, Emory University; Nancy Newman, Emory University; Valerie Biousse, Emory University; Beau Bruce, Emory University
• Journal Title: World Neurosurgery
• Volume: Volume 94
• Publisher: Elsevier | 2016-10, Pages 447-452
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.wneu.2016.07.026
• Subjects: Biology, Neuroscience; Health Sciences, Opthamology; Health Sciences, Epidemiology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Clinical Neurology; Surgery; Neurosciences & Neurology; Cranial nerve palsy; Diplopia; Pituitary adenoma; Pituitary apoplexy; TRANSSPHENOIDAL SURGERY; CLINICAL-FEATURES; MANAGEMENT; HEMORRHAGE; ADENOMAS; SERIES; TUMORS; EXPERIENCE; OUTCOMES

Abstract

Background Pituitary apoplexy (PA) often presents with acute headache and neuro-ophthalmic manifestations, including ocular motility dysfunction (OMD) from cranial nerve palsies (CNPs). Our goal was to describe the epidemiology and outcomes of OMD in a large, single-center series of patients with PA. Methods We conducted a retrospective chart review of all patients with PA seen in our pituitary center between January 1995 and December 2012. Presenting neuro-ophthalmic, endocrine, and radiologic data, as well as neuro-ophthalmology follow-up data, were collected. Results We identified 235 patients with PA, 59 of whom (25%) had OMD. Twenty-seven of those 59 patients underwent neuro-ophthalmic evaluation. Preoperatively, 23 of these 27 patients had unilateral OMD, 18 (78%) with a single CNP and 5 (22%) with multiple CNPs. Bilateral OMD was present in 4 of the 27 patients. Postoperatively, 24 of the 27 patients with OMD had follow-up (median duration, 7 months; interquartile range [IQR], 3–17 months). At the last postoperative follow-up, 7 of these 24 patients (29%) had OMD (5 unilateral, 2 bilateral). OMD resolved in 3 of the 24 patients (12%) within 1 month, in 13 of 21 patients (62%) within 6 months (3 lost to follow-up), and in 17 of 19 patients (89%) within 1 year (2 lost to follow-up). Surgery was performed at ≤14 days after presentation in 16 of 18 (89%) resolved cases and in 4 of 6 (67%) unresolved cases. Patients with OMD were more likely than those without OMD to have larger tumors (2.6 vs. 2.0 cm; P < 0.001), panhypopituitarism (31% vs. 14%; P = 0.005), and necrosis (58% vs. 37%; P = 0.03). Conclusions OMD from CNPs is common in PA, occurring in one-quarter of patients, and is frequently associated with certain radiologic, endocrinologic, and pathological features. The prognosis is excellent, with 90% of cases of OMD resolving by 1 year after early pituitary surgery.